JOIN US FOR A FECAL INCONTINENCE VIRTUAL CONFERENCE AT 6:00 PM ON TUESDAY, FEBRUARY 23. THE DISCUSSION WILL BE HOSTED BY DR. HEATHER MATHESON AND IS SPONSORED BY MEDTRONIC.
DR. MATHESON WILL DISCUSS THE EVALUATION AND TREATMENT OF INCONTINENCE INCLUDING THE NEWEST TECHNIQUE OF ‘SACRAL NERVE STIMULATION’ THERAPY. THERE WILL BE TIME FOR QUESTIONS FOLLOWING HER PRESENTATION.
THE TERM INFLAMMATORY BOWEL DISEASE REFERS TO TWO DISEASES; ULCERATIVE COLITITIS AND CROHN’S DISEASE.THESE DISEASES CAUSE INFLAMMATION OF THE BOWEL. THE CAUSE OF EACH REMAINS UNKNOWN, THOUGH THERE IS INCREASING EVIDENCE THAT THEY MAY BE RELATED TO COMPLEX INTERACTIONS BETWEEN THE BACTERIA OF THE GUT WITH DIET, ANTIBIOTICS, AND OTHER INTERNAL OR EXTERNAL FACTORS. BOTH DISEASES CAUSE NON-SPECIFIC INFLAMMATION OF THE GI TRACK. THIS RESULTS IN SYMPTOMS WHICH ARE COMMON TO BOTH DISEASES.
ULCERATIVE COLITIS ( UC ) INVOLVES ONLY THE COLON WITH THE INFLAMMATION LIMITED TO THE MUCOSA ( INTERNAL LINING ) . THE DISEASE IS ALSO CONTINUOUS, BEGINNING IN THE LOWER RECTUM WITH EXTENSION ANYWHERE FROM ONLY A FEW INCHES TO INVOLVEMENT OF THE ENTIRE COLON. THERE ARE NO SKIP AREAS. CROHN’S DISEASE ( CD ), IN CONTRAST, CAN INVOLVE ANY PORTION OF THE GI TRACK FROM THE MOUTH TO THE ANUS, AND CAN CAUSE FULL THICKNESS INFLAMMATION OF THE BOWEL WALL. SKIP AREAS ARE ALSO COMMON. THIS DISEASE OFTEN PRESENTS WITH INVOLVEMENT OF THE LAST PORTION OF THE SMALL BOWEL ( TERMINAL ILEUM ) AND THE RIGHT SIDE OF THE COLON IN THE AREA OF THE APPENDIX.
THE SYMPTOMS ARE SIMILAR IN BOTH DISEASES AND CONSIST OF CHANGES IN BOWEL PATTERN WITH LOOSE STOOL, URGENCY TO HAVE A BOWEL MOVEMENT, CRAMPING, BLEEDING, ABDOMINAL TENDERNESS, AND ANORECTAL DISCOMFORT IN PATIENTS WITH WITH ABCESSES, FISTULAE AND FISSURES. IN LONGSTANDING CASES WITH PROLONGED SYMPTOMS AND LACK OF ADEQUATE DIETARY INTAKE PATIENTS CAN DEVELOP SEVERE WEIGHT LOSS AND BECOME MALNOURISHED.
EVALUATION OF PATIENTS BEGINS WITH A THOROUGH HISTORY AND PHYSICAL EXAM FOLLOWED BY TESTING WHICH CAN INCLUDE BLOOD WORK LOOKING FOR MARKERS FOUND WITH INFLAMMATORY BOWEL DISEASE. ALMOST ALL PATIENTS WILL REQUIRE EXAMINATION OF THE GI TRACT WITH DIRECT OBSERVATION AND BIOPSIES. THIS WILL INCLUDE COLONOSCOPY AND SOMETIMES UPPER ENDOSCOPY AND CAPSULE ENDOSCOPY. IT IS IMPORTANT TO DETERMINE THE EXTENT AND SEVERITY OF THE DISEASE TO GUIDE MEDICAL AND SURGICAL TREATMENT IN THOSE PATIENTS WHERE SURGERY IS NEEDED. IT IS ALSO IMPORTANT TO RULE OUT OTHER CAUSES OF INFLAMMATION SUCH AS INFECTIONS, IRRITABLE BOWEL, MEDICATION EFFECTS INCLUDING ANTIBIOTICS, AND TUMORS…BOTH BENIGN AND MALIGNANT.
IN ADDITION TO THE SYMPTOMS CAUSED BY THE INFLAMMATION, APPROXIMATELY 20% OF PATIENTS MAY EXPERIENCE WHAT ARE CALLED EXTRA-INTESTINAL PROBLEMS SUCH AS DERMATITIS, ARTHRITIS, AND INFLAMMATION IN OTHER PARTS OF THE BODY.
MEDICATIONS USED TO BRING THE SYMPTOMS UNDER CONTROL FALL INTO SEVERAL CATEGORIES;
2) AMINOSALICYLATES ( ANTI-INFLAMMATORY ), WHICH CAN BE USED BOTH ORALLY AND RECTALLY.
4) MONOCLONAL ANTIBODY THERAPY ( INFLIXIMAB, ADALIMUMAB )
5) ANTIBIOTICS ( CIPRO, FLAGYL )
THESE MEDICATIONS WORK IN DIFFERENT WAYS TO DECREASE THE INFLAMMATION BEING CAUSED BY THE DISEASE, WITH ANTIBIOTICS SOMETIMES USED FOR TREATMENT OF ANORECTAL DISEASE.
WHEN MEDICAL THERAPY FAILS TO CONTROL THE DISEASE, WITH DEVELOPMENT OF COMPLICATIONS OR CHRONIC DEBILITATING SYMPTOMS, SURGICAL THERAPY IS INDICATED. THE SURGICAL THERAPY IS VERY DIFFERENT FOR THE TWO DISEASES. WITH UC, REMOVAL OF THE COLON IS CURATIVE. THIS CAN BE ACCOMPLISHED BY REMOVING THE ENTIRE COLON AND RECTUM WITH CREATION OF AN ILEOSTOMY, OR AS IS DONE MORE COMMONLY IN THE LAST 30 YEARS, REMOVAL OF THE ENTIRE COLON AND RECTUM WITH CREATION OF A ‘J’ POUCH FROM THE SMALL BOWEL TO SERVE AS AN ARTIFICIAL RECTUM.
CROHN’S DISEASE IN CONTRAST IS NOT CURATIVE BY SURGICAL REMOVAL, AS 40% OR MORE OF PATIENTS WILL EVENTUALLY DEVELOP RECURRENT DISEASE. FOR THIS REASON IN CROHN’S PATIENTS REQUIRING SURGERY, ONLY THE INVOLVED SEGMENTS OF SMALL BOWEL OR COLON ARE REMOVED. MOST PATIENTS ARE THEN CONTINUED ON LONG TERM MEDICAL THERAPY.
CHRONIC RECTAL OR PELVIC PAIN As we have discussed in previous articles, there are 3 common causes of rectal pain. THROMBOSED HEMORRHOIDS, FISSURES, AND ABCESSES. There are a number of causes of less significant irritation such as pruritus, skin tags, and anything else that can irritate the skin.
The least common cause of pain falls in the category of something we call Levator Syndrome/Spastic Levator/Pelvic Floor syndrome, or Chronic Proctalgia. Proctalgia literally translates to ‘rectal pain’. This can be intermittent discomfort which occurs over a matter of a few minutes and dissipates just as quickly, typically occurring at night, and called Proctalgia Fugax ( fleeting pain in the rectum ); or more chronic pain which can last days, weeks or in some cases many years. We refer to this more chronic discomfort as Levator or Pelvic floor syndrome. Although this has been related to pelvic surgery, or certain jobs requiring prolonged sitting or maintaining certain positioning, my experience has been that most often I can find no obvious cause! I have in fact seen it in a patient who had no rectum, it having been removed for inflammatory bowel disease many years before. Though we often use the term rectal to describe the pain, it is in fact in the muscles of the pelvic floor and the sphincter muscles. Examination will show no abnormalities on anorectal exam and colonoscopy. The diagnosis is made by eliciting pain on rectal exam within the sphincter and levator muscles of the pelvic floor. It is most often more severe on the left side.
Treatment can be difficult but is successful in most patients. It consists of warm sitz baths to relax and sooth the muscles. Physical Therapy including Kegel exercises and quite often Physical Therapy referral for more specialized treatment. If these measures alone are not effective, medicines such as Elavil ( amitriptyline ) can be used in low doses to bring about relief of pain. Though it is a benign disease it can be quite bothersome to patients. It is important when treating to remind patients that although it can take time, the majority of patients will get relief of their pain.
If you are suffering rectal pain, change in bowel pattern, rectal bleeding, or any colonic symptom…seek the advice of a Colorectal Surgeon! Remember, patients treated by Colorectal Surgeons have better outcomes. WWW.colondocs.net
A question many patients ask us, often joking, is “what made you want to become a butt doctor?”
The answer is actually much simpler than you think. We love it! We have a passion for it! We enjoy the work! Does that sound crazy? Well it’s far from crazy and here’s why.
Colorectal surgery can be difficult, the anatomy and physiology, the surgical technique. It requires extra training. But it’s also difficult physically and emotionally for patients and their families. Undergoing the exams and treatment can be embarrassing! Whether dealing with a painful but benign anorectal problem or a colon cancer. To paraphrase something President Kennedy said about the space program; we don’t choose to do it because it is easy, we choose to do it because it is hard! We want our community, the Tri-state area to have the finest in colorectal care. We want every patients to feel as comfortable and safe as possible during what is a very stressful time. We want them to have the very best in care and the best outcomes possible. Outcomes that we know are better when done by a Colorectal Surgeon. With this comes much satisfaction…and we receive from our patients, families, and community much more than we could ever give! It is a joy and a privilege to get to do what we do; to go to work each morning. So yes, we love it, and that fuels in us a passion to strive to be better every day.
The Physicians and Staff of Tri-State Colorectal
Quite simply, fecal incontinence refers to the inability to control bowel movements; resulting in the accidental loss of stool. This is a very significant problem for anyone affected. It can be debilitating to the point of making one a ‘bathroom cripple’; as it can be almost impossible to leave the house. In its mildest form patients might experience minimal seepage and drainage. In more serious cases, there is no control of bowel movements. The symptoms can be brought on by anything which changes stool consistency causing loose stool. This can be as simple as dietary factors; or more significant diseases causing inflammation of the colon. If there is no underlying muscle weakness, simply treating the underlying condition, correcting the loose stool, will treat the problem. Conditions caused by muscle weakness may also be treated by thickening the stool; but also require thorough examination of the pelvic floor muscles to evaluate their function. In many cases treatment of both stool consistency and muscle weakness are required to bring the patient adequate control.
The problem is much more common than physicians previously suspected. In the past there were few effective treatments and physicians and patients were reluctant to talk about the problem. We now recognize that it is a very common problem, especially among women who have had natural childbirth. During childbirth there is stretching and injury to the pelvic floor muscles and nerves. This causes temporary weakness that usually causes no problems in young women with normal muscle strength. Over time however, many women will experience gradual ongoing deterioration of nerve and muscle function, with increasing weakness. This results in worsening symptoms of leakage as they approach their 50s and 60s. This is in contrast to someone who has a significant muscle injury during childbirth, or patients who suffer an injury as a result of trauma. These patients respond well to simple muscle repair at the time of injury. This is in stark contrast to older women found to have a muscle defect from previous injury. Muscle repair is rarely successful in these patients. In fact, non operative treatment is very effective in most patients. Evaluation of patients suffering from symptoms of incontinence include a detailed history and physical exam. Examination quite often requires colonoscopy to rule out cancer or inflammation. In addition to standard rectal exam; ultrasound is used to examine the muscle for any possible defects and manometry is done to evaluate the strength of the muscle. Ultrasound and manometry can both be performed in the comfort of our office; taking only a few minutes to complete.
Treatment is then determined by the findings on our exams. We quite often will start by taking measures to thicken the stool such as the use of fiber products and antidiarrheal medicines. Physical therapy can be started to strengthen the muscles. For those people who fail medical treatment there are a couple of surgical options depending upon findings on ultrasound. As mentioned above, with significant muscle disruption, a surgical repair can be done. Unfortunately this has been found to be of limited effectiveness, and is rarely attempted.
In recent years a minimally invasive treatment using electrical nerve stimulation has been developed which has revolutionized the treatment of incontinence. Using a device called a sacral nerve stimulator, the nerves to the pelvic floor can be stimulated; improving muscle function and control. The device is placed under the skin as an outpatient procedure, much like a pacemaker is used for the heart.
In summary; we now have very effective treatment for incontinence! No need to suffer in silence!
If you are experiencing symptoms of incontinence, or have any other colorectal problems; contact us. As Colorectal Surgeons we have the training and expertise to best evaluate and treat your colorectal problems. Thank you, The physicians and staff of Tri-State Colorectal
Rectal pain, or more correctly, anal pain; has a number of causes. I say anal pain because the lower rectum and the internal anal canal are not sensitive to pain in the usual sense. These portions of the intestinal track are lined by cells found within the intestinal track and supplied by ‘gut’ nerve fibers which are not sensitive to sharp pain. This allows us to treat internal hemorrhoids, which line the internal anal canal, very differently than external hemorrhoids and other conditions which can cause anal (anorectal ) pain. In fact, this is what allows us to remove polyps or do biopsies during colonoscopy without causing any post procedure pain. Keep this in mind as we discuss the causes of anorectal pain. With conditions affecting the rectum or internal anal canal, patients may have a sensation of pressure or an uncomfortable urge to go to the bathroom; but not the type of pain that we experience from an injury to the skin or ‘external’ anal canal. The external anal canal is lined with a modified type of skin cell and nerve fibers which make it very sensitive to pain! Most of us have experienced this at one time or another during our lives. The program director of my Colorectal Surgery residency had a saying “you don’t have to be a genius to be a colorectal surgeon”. The reason; there are only three common causes of anorectal pain, and all three are visible without inserting a finger or a scope!
There are other causes of less severe discomfort such as pruritus ( burning and itching ), skin tags, anal warts, and even muscular pain within the pelvic floor. Notice that thrombosed hemorrhoids are one of only a number of conditions, and not even the most common! As I have pointed out in previous articles, hemorrhoids are normal structures. They consist of columns of vascular tissue within the anal canal. That portion within the INTERNAL anal canal is relatively insensitive to pain, can cause painless bleeding and protrusion, and can be treated by a variety of methods including the most common; hemorrhoid ligation. The hemorrhoidal tissue lying within the external canal, which is the area just around anal opening and within the lower 1-2 cm of the anal opening, is very sensitive to pain. As most of us are aware, even those of us in the medical profession; most health care workers and patients refer to any anorectal pain as being a ‘hemorrhoid’. I have seen countless patients referred to me over the years being told that they had a ‘hemorrhoid’, regardless of their symptoms. Though it is technically true that they have a hemorrhoid, most patients have another cause of their discomfort. In my practice I found the most common cause of pain to be an anal fissure. More about that later. I started all my medical school lectures with the phrase, “all that hurts in the anorectal area is not a hemorrhoid!’ In fact, the only time a hemorrhoid causes pain is when one or more of the 3 hemorrhoids becomes thrombosed. Thrombosed hemorrhoids occur when the the blood vessels within the hemorrhoid become clotted ( thrombosed). This causes swelling, inflammation and pain. The swelling is visible on simple inspection and visualization of the area. The level of pain is dependent upon the amount of clot and whether a single or all three hemorrhoids are involved. Despite the severity of the thrombosis, all cases will resolve on there own, with the pain subsiding in from 3-10 days with the use of warm soaks, topical ointment, and pain medicines. Surgery is never mandatory but can be done in patients with recurrent episodes in order to prevent recurrences. Surgery is painful but effective with a recurrence rate under 5%. The decision to have surgery is strictly up to the patient after consultation with their physician. Anal fissures consist of a crack or tear in the lining of the external anal canal.They are most commonly caused by a hard bowel movement resulting in the tear. Sphincter muscle spasm complicates the condition by causing pain and further difficulty in passing stool. In fact, the muscle spasm is the primary cause of pain. Treatment consists of increasing fiber in the diet, often with the use of a psyllium product, warm soaks, and the application of a topical ointment, or injection of botox, designed to break the muscle spasm. Medical therapy is effective in over 80% of patients. Surgical treatment consists of a partial sphincterotomy ( division of the lowermost fibers of the sphincter ) in order to break the spasm: it is effective in 95% of patients. Anorectal abcess occurs when one of the small mucous glands within the anal canal becomes infected. As with abcesses in other parts of the body they present with swelling, pain, redness and sometimes drainage. The treatment for these is incision and drainage, preferably by a surgeon familiar with the anatomy of the anal canal. There is no place for antibiotics except in patients with severe infections or other complicating conditions… and only after incision and drainage. Several important points to make, especially with the wave of devices advertised to treat hemorrhoids ‘painlessly’ or ‘in the office’.
1) These treatments are strictly for internal hemorrhoids; and only those with symptoms of painless bleeding or protrusion. They should only be done by a physician with specific training in the anatomy, diseases and treatment of anorectal problems 2) If you have a painful condition; seek expert consultation. Thrombosed hemorrhoids, fissures, abcess, skin tags, warts and other skin or muscular pain cannot be treated with a device or technique designed to treat internal hemorrhoids. Seek expert consultation with a Colorectal Surgeon. 3) Patients treated by Colorectal Surgeons have better outcomes!
Thank you, the physicians and Staff of Tri-State Colorectal.